RUEL M. BERSABES OUR LADY OF PERPETUAL HELP REVIEW CENTER CHED Accreditation No.

73 FUNDAMENTALS OF NURSING A New Updates December 2010 1. While providing nursing care for the client in Bucks traction, which assessment finding indicates a need for immediate action? 1. The traction weights are hanging above the floor. 2. The leg is in line with the pull of the traction. 3. The clients foot is touching the end of the bed. 4. The rope is in the groove of the traction pulley. The nurse enters the clients room to assess the traction apparatus. Which of the following interferes with the effectiveness of the Russells traction? 1. The rope is strung tautly from pulley to pulley. 2. The trapeze is hanging above the clients chest. 3. The rope is knotted at the location of a pulley. 4. The weight is hanging about 24 inches from the floor. If the client is allergic to penicillin, it is essential that the nurse question the medical order prior to giving which type of antibiotic? 1. Aminoglycosides like gentamicin sulfate (Garamycin) 2. Cephalosporins like cefaclor (Ceclor) 3. Tetracyclines like doxycyline (Vibramycin)

9.

Which item is best for preventing external rotation of the operative leg when caring for the client with the total hip replacement?

1.
2. 3. 4.

A A A A

footboard trochanter roll turning sheet foam mattress

10. The

nursing explanation that best describes the primary purpose of the CPM machine is that it is used to.

2.

3.

4. 4.

Sulfonamides like sulfamethoxazole (Bactrim)

trimethoprim-

Strengthen leg muscle 2. relieve foot swelling 3. Reduce surgical pain. 4. Restore joint function. 11. If the physician orders the following laboratory tests to determine gout, the elevation of which test validates the clients diagnosis? 1. Creatinine clearance 2. Blood urea nitrogen 3. Serum uric acid 4. Serum calcium 12. The client with gout experiences an acute attack. Which piece of equipment is best for promoting his comfort? 1. A bed cradle 2. An electric fan 3. A foam mattress 4. A fracture bedpan The physician orders transcutaneous electric nerve stimulation (TENS) in the location of the discomfort on the arm opposite the amputation. 13. When the client asks the nurse how the TENS unit works, you respond that one of the most widely held theories is that sensation created by the TENS machine. 1. Blocks the brains perception of pain impulses. Travels to the nerve root amputated arm. 3. Destroys the brains pain center. 4. Weakens the arms sensory nerves. A myelogram with a water-soluble contrast dye is ordered to confirm the diagnosis of a herniated intervertebral disk. 14. After the client returns from the myelogram. It is most appropriate for the nurse to keep the client quiet and to. 1. Reduce glare from bright lights. 2. Withhold food and fluids for 12 hours. 3. Administer sedatives every 6 hour. 4. Encourage a high fluid intake. The physician plans to do a lumbar puncture (spinal tap) on the client who may have meningitis. 15. To facilitate performing the lumbar puncture, it is best for the nurse to place the client. 1. In a knee-chest (genupectoral) position 2. Sitting up in an orthopnic position 3. In a side-lying position with his neck flexed. 4. In a left lateral position with right knee flexed. 16. While awaiting the results of diagnostic tests best to care for the client with possible meningitis. 1. Droplet precaution. 2. Airborne precautions. 3. Contact precautions 4. Standard precautions A 23 year-old woman who experienced a generalized seizure while at work is undergoing diagnostic tests.

1.

2.

Which laboratory test, if elevated, is most diagnostic for rheumatoid arthritis? 1. Erythrocyte sedimentation rate (ESR) 2. Partial thromboplastin time (PTT) 3. Fasting blood sugar (FBS) 4. Blood urea nitrogen (BUN)

A cervical halter type of skin traction is applied to a client who has experienced a whiplash injury in a motor vehicle accident. 5. When the nurse makes rounds at the beginning of the shift, which observation requires immediate attention? 1. The halter rest under the clients chin and occiput. 2. The clients ears are clear of the traction ropes. 3. The weight hangs between the headboard and wall. 4. There is a soft pillow beneath the clients head. 6. Which statement made by the client indicates that further instruction regarding corticosteroid therapy is necessary? 1. I am susceptible to getting infections. 2. I should never stop taking my medication abruptly.

3. 4.

I may become very depressed and perhaps suicidal. I may develop low blood sugar and need glucose.

17. When

Before the total hip replacement, the nurse teaches the client how to use an incentive spirometer. 7. Which client statement indicates that he has a correct understanding of its use? 1. I should position the mouthpiece and inhale deeply. 2. I should position the mouthpiece and exhale forcefully. 3. I should position the mouthpiece and cough effectively. 4. I should position the mouthpiece and breathe naturally. 8. After the client undergoes a total hip replacement, how should the nurse position the affected hip?

preparing a client for an electroencephalogram (EEG), which nursing action is appropriate to perform? 1. Administer a pretest sedative an hour before. 2. Withhold food and water after midnight. 3. Assist the client with shampooing her hair. 4. Take clients blood pressure lying and sitting. 18. When implementing this order, which nursing action is most appropriate? the client is moved to a room close to the nursing station. 2. The clients food is served in paper and plastic containers. 3. The overhead light is left on at all times. 4. The side rails on the bed are softly padded. 19. When the client who has had an EEG begins to have a seizure, which action should the nurse take first? 1. Administer oxygen by nasal cannula. 2. Take her blood pressure and pulse. 3. Restrain her arms and upper body. 4. Place her in a side-lying position.

1.

1.
2. 3. 4.

Adduction Abduction Flexion Extension

The medical record of a client with epilepsy indicates that he has had two previous episodes of status epilepticus. 20. Which emergency drug should the nurse plan to have available in case the client has a similar episode? 1. Diazepam (Valium) 2. Phenytoin (Dilantin) 3. Carbamazepine (tegretol) 4. Phenobarbital sodium (Luminal) A computed tomography scan (CT) of the brain with contrast dye is ordered on the unconscious client. 21. If the clients wife reports that the client has allergies, which one must be reported to the physician before the CT? 1. Tomatoes 2. Shellfish 3. Chocolate 4. Strawberries A client with symptoms that suggest a brain tumor is scheduled for positron tomography (PET). 22. When the nurse provides test preparation instructions, which substance is it important for the client to avoid the day before the rest? 1. Caffeine 2. Food dyes 3. Diuretics 4. Antibiotics

A client asks the nurse why adults do not experience middle ear infections as frequently as children do. 29. The nurse is most correct in explaining that, in a child, organisms travel more easily from the nasopharynx to the middle ear because the Eustachian tube is. 1. Shorter and straighter.

2.
3. 4.

Longer and straighter. Shorter and more curved. Longer and more curved.

The client with possible Menieres disease will undergo a caloric test. 30. The teaching plan for preparing the client for this diagnostic test includes the explanation that. 1. Cold water and warm water are instilled in each ear. 2. Earphones are worn through which sounds are transmitted. 3. Scalp electrodes are attached to the head in a darkened room. 4. Blood is drawn from a vein and examined microscopically. A nursing assistant with an allergy to latex asks the nurse advice on carrying out standard precautions for preventing transmission of blood-borne viruses. 31. The best advice the nurse give is to. 1. Rinse the latex gloves with running tap before donning them.

23. Before

the client is discharged following the PET, which instruction is most appropriate? 1. Take a mild laxative tonight. 2. Increase your fluid intake. 3. Get at least 8 hours of sleep. 4. Report any abdominal discomfort.

2. 3.

Apply a petroleum ointment to both hands before donning latex gloves.

The client who underwent a craniotomy returns to the nursing unit after 6 hours of surgery. 24. During the immediate postoperative assessment when the nurse notes that the clients dressing is moist, which action is most appropriate to take first? 1. The nurse changes the dressing. 2. The nurse reinforces the dressing. 3. The nurse removes the dressing. 4. the nurse documents the findings. A client experiences recurrent pain along the sciatic nerve. The client is scheduled for a myelogram. 25. When the the client, 1. 2. 3. nurse describes the myelogram procedure to which statement is most accurate? part of the test involves a lumbar puncture. You will be asked to change positions frequently. Dye will be instilled into a vein in your arm. Light anesthesia is administered during the test.

Eliminate wearing gloves, but wash both hands vigorously with alcohol afterward. 4. Wear two pairs of vinyl gloves when there potential for contract with blood. The client with diabetes insipidus is treated with intranasal lypressin (Diapid), 2 sprays q.i.d. and as needed. 32. The nurse observes the client self-administering the medication. Which action indicates that the client is performing the procedure correctly? The client assumes a supine position. 2. The client tilts her head to the side. 3. The client inverts the drug container. 4. The client inhales with each spray. The client with acromegaly will undergo a transsphenoidal hypophysectomy after a short course of theraphy with bromocriptine (Parlodel). 33. Because bromocriptine (Parlodel) may cause postural hypotension, which nursing instruction is most appropriate? 1. Lie down for hour after taking the medication. 2. Avoid taking elevators in tall buildings. 3. Rise slowly from a sitting or lying position. 4. Have your blood pressure taken once a week. A 35 year-old woman is undergoing test to determine why she has stopped menstruating. One test that the client undergoes is a radioactive iodine uptake test.

1.

4.

26. Postoperatively, the client who has had a cataract extraction tells the nurse that he is experiencing severe pain in his operative eye. Which nursing action is most appropriate?

1.
2. 3. 4.

Report the finding to the nurse in charge. Give the clients prescribed analgesic. Assess the clients pupil response with a penlight. Reposition the client on the operative. Side.

34. When

27. It is essential that the nurse withholds medication administration and notifies the physician if which drug is ordered for a client with glaucoma? 1. Atropine sulfate 2. Morphine sulfate 3. Magnesium sulfate 4. Ferrous sulfate 28. Which instrument is most appropriate for the nurse to use for the purpose of testing the clients hearing acuity? 1. Otoscope 2. Tuning fork 3. Reflex hammer 4. Stethoscope

the test is completed, which of the nurses statements is accurate? 1. You must remain isolated until your radiation is decreased. 2. You are free to go without further precautionary instruction. 3. You must follow special precaution for a short period of time. 4. You will be given an antidote for reducing the radioactivity.

The client is stable condition returns to the nursing unit after having a subtotal thyroidectomy. 35. In which position is it most appropriate to maintain the client following a subtotal thyroidectomy? 1. Supine 2. Sims 3. Fowlers 4. Recumbent

The care plan indicates that the nurse should assess the Chvosteks sign if hypocalcemia is suspected. 36. Which technique best describes how Chvosteks sign is elicited?

1. 2.
3. 4.

The nurse lightly taps over the client facial nerve. The nurse strokes the sole of the clients foot. The nurse dorsiflexes each of the clients feet. the nurse asks the client to touch her nose.

Pierce the central pad of the clients finger. Apply a large drop of blood to a test strip or area. 44. Which action best indicates that the client needs more practice in combining two insulins in one syringe? 1. The client rolls the vial of intermediate-acting insulin to mix it with its additive. 2. The client instills air into both the fast-acting and intermediate-acting insulin vials.

3. 4.

3.
4.

A client with hyppoparathyroidism develops tetany. 37. If emergency drugs are available, which one can the nurse expert the physician will order for intravenous administration? 1. Calcium gluconate

The client instills the intermediate-acting insulin into the vial of rapid-acting insulin. The client inverts each vial prior to withdrawing the specified amount of insulin.

2.
3. 4.

Ferrous sulfate Potassium chloride Sodium bicarbonate.

45. When the client practices self-administration of the insulin, which action is correct? 1. Piercing the skin at a 30-degree angle. 2. Using a syringe calibrated in minims. 3. Using a 2-inch needle on the syringe 4. Rotating the sites of each injection. 46. Which instruction by the nurse should be given to the client regarding insulin administration during sick days? 1. Monitor blood glucose levels every 2 to 4 hours. 2. Eat candy or sugar frequently. 3. Attempt to drink a high-calorie beverage every hour. 4. Test urine daily fro protein. 47. As the nurse prepares to withdraw the furosemide (Lasix) from the ampule the best technique for removing the medication is to. 1. Allow the ampule to stand undisturbed for a few minutes. 2. Tap the ampule stem with the fingernail a few times.

The physician orders a 24-hour urine collection to aid in the diagnosis of Cushings syndrome. 38. The nurse most accurate in instructing the client that the urine collection will begin 1. With the clients next voiding. 2. After the clients next voiding. 3. At midnight. 4. At noontime. A 5-hour glucose test is ordered to determine if the client has functional hypoglycemia. 39. Which nursing instruction concerning the test procedure is most accurate? 1. You need to eat a large meal just before the test. 2. Bring a voided urine specimen to the laboratory.

3.
4.

3.
4.

You can have liquids, like coffee, before the test. You will be given a sweetened drink before the test.

Hold the ampule upside down, then flip it right side up. Roll the ampule gently between the palms of the hands.

48. The

A nurse participates in a community-wide screening to identify adults who may have undiagnosed diabetes mellitus. 40. If the screening includes a measurement of postprandial blood sugar, the nurse is correct in explaining that blood will be drawn approximately 2 hours. 1. Before breakfast. 2. After meal. 3. Before bedtime. 4. After a fast. 41. Which statement indicates that a client with an elevated 2-hour postprandial blood sugar understands the significance of the screening test? 1. I need to eat less frequently.

best evidence that turosemide (Lasix) has had a therapeutic effect is that the clients. 1. Pulse becomes slower. 2. Blood pressure stabilizes. 3. Urinary output increases. 4. Anxiety is diminished.

49. The nurse should instruct the client to take his oral furosemide (Lasix) at what time of the day? 1. Before bedtime. 2. When arising. 3. With his main meal. 4. In the late afternoon. 50. When teaching the client about the side effects of furosemide (Lasix), the nurse instructs him that he will need to eat foods high in which mineral? 1. Potassium. 2. Sodium 3. Calcium 4. Iron 51. The nurse instructs the client taking furosemide (Lasix) to monitor his urine output. The rationale for the nurses instruction is that the use of furosemide (Lasix) may lead to which condition? 1. Dehydration 2. Fluid overload 3. Hypernatremia 4. Hyperkalemia The client is scheduled for a stress electrocardiogram (ECG).

2.
3. 4.

I need to stop eating candy. I need to consult my physician. I need to begin taking insulin.

The physician prescribes glyburide (DiaBeta) orally for the client with type II diabetes mellitus. 42. When the client asks why his diabetic relative cannot take his insulin orally, the best answer is that insulin is 1. Inactivated by digestive enzymes. 2. Absorbed too quickly in the stomach. 3. Irritating to the gastric mucosa. 4. Incompatible with many foods. The nurse plans to monitor the clients response to insulin therapy closely with an electronic glucometer. 43. When the nurse monitors the clients blood sugar using an electronic glucometer, which action is correct?

52. When

1. 2.

Clean the clients finger with povidone iodine (Betadine). Apply a rubber band around the test finger.

the client asks why the physician ordered the ECG, it is most correct for the nurse to explain that a stress ECG. 1. Shows how the heart performs during exercise. 2. Determine his potential target heart rate. 3. Verifies how much he needs to improve his fitness. 4. Can predict if he will have a heart attack soon.

53. Which side effect is most closely associated with the use of nitrogen tablets? 1. Headache 2. Backache 3. Diarrhea 4. Jaundice 54. It is most accurate for the nurse to tell the client that if his chest pain is not relieved after taking one nitroglycerin tablet he should. 1. Take another tablet in 5 minutes. 2. Drive of the emergency department. 3. Call his physician without delay. 4. Swallow two additional tablets.

3. 4.

Section of vein from his leg will be grafted around a narrowed coronary artery. Battery-operated pacemaker will be implanted to maintain his heart rate.

While waiting to undergo PTCA, the client takes propranolol hydrochloride (Inderal). 62. When the client asks the nurse how this drug helps to prevent angina, the best explanation is that it

1.
2. 3. 4.

Promotes excretion of body fluid Reduces the rate of heart contribution. Alters pain receptors in the brain. Dilates the major coronary arteries.

55. Which

nursing action is most appropriate when applying the transdermal patch? 1. Rotate the application site. 2. Squeeze the drug reservoir. 3. Tape the patch to the chest. 4. Apply ice to the skin area.

The client who is awaiting a PTCA has been taking one baby aspirin daily per the advice of his physician. 63. The best explanation for the drug therapy in this situation is that aspirin tends to 1. Relieve chest pain 2. Prevent blood clots 3. Reduce muscle spasms 4. Reduce joint inflammation. 64. When the client returns to his room following the PTCA procedure, which assessment finding should be reported immediately to the physician? 1. Urine output of 100 mL/h 2. Blood pressure of 108/68 mm Hg 3. Dry mouth 4. Chest pain The client who has a previous PTCA is now scheduled for a coronary artery bypass graft (CBAG). 65 . Immediately after returning to the unit, the nurse assesses the clients leg incision. The nurse is aware that the most common blood vessel used in CABG surgery is the 1. 2. 3. 4. Saphenous vein. Femoral artery. Popliteal vein. Iliac artery.

56. Prior to the catheterization and coronary arteriogram, it is essential that the nurse ask the client if he allergic to iodine or. 1. Penicillin. 2. Morphine. 3. Shellfish 4. Eggs.

57. The client who has been experiencing increased incidence

of chest pain will undergo a heart catheterization and coronary arteriogram. To reduce the clients anxiety, it is best for the nurse to. 1. 2. 3. 4. Teach the client how coronary artery disease is usually treated. Listen to the client express his feelings about his condition. Explain to the client how well others have done having this test. Avoid discussing the heart catheterization until client has relaxed.

58. The nurse implements the teaching plan for cardiac catheterization and coronary arteriogram. 1. The client says that he will be able to hear beating in his chest. 2. The client says that he will experience a heavy sensation all over his body. 3. The client says that he will be anesthetized and wont feel any discomfort. 4. The client says that he will feel a warm sensation as the dye is instilled. The femoral artery is the site used to thread the heart catheter. 59. After the coronary arteriogram, the nurse correctly keeps the client flat in bed with the affected leg. 1. Extended 2. Flexed 3. Abducted 4. Abducted. 60. After the femoral artery has been cannulated, the most important physical assessment the nurse should plan is to 1. Palpate the clients distal peripheral pulses. 2. Auscultate the clients heart and lung sounds. 3. Percuss all four quadrants of the clients abdomen. 4. Inspect the skin integrity in the clients groin. Based on the results of the coronary arteriogram, the physician recommends that the client undergo percutaneous transluminal coronary angioplasty (PTCA).

The physician orders a patient-controlled analgesia (PCA) infuser pump for the client following CABG surgery. 66. The nurse instructs the client about the use of the PCA pump. Which information is most important for the nurse to provide? 1. Press the control button when pain medication is needed. 2. Call the nurse each time the PCA pump needs to be used. 3. Use the PCA pump only when the pain is severe. 4. Frequent use of the PCA pump can cause addiction. After the CABG surgery, which assessment finding provides the best evidence that collateral circulation at the donor graft site is adequate? 1. The client is free of chest pain. 2. The toes are warm and nonedematous. 3. The client moves his leg easily. 4. The heart rate remains regular. 68. Which drug should the nurse plan to have on hand in case the client who receives streptokinase (Streptase) develops an allergic reaction? 1. Vitamin K (Synkayvite) 2. Heparin sodium (Liquaemin sodium) 3. Diphenhydramine (Benadryl) 4. Warfarin sodium (Coumadin) A 65 year-old woman collapse in the hospital elevator while coming to visit a family member. 69. The first action the nurse who discovers her should take is to 1. Open her airway. 2. Give two breaths. 3. Shake her gently. 4. Call a code blue. 70. Which technique is best for the nurse to use to open the airway of the person who is not breathing? 1. Elevate the neck. 2. Lift the chin. 3. Press on the jaws.

67.

61. If

the client understands his physicians explanation of the PTCA procedure, he will describe that a 1. Balloon-tipped catheter will be inserted into a coronary artery. 2. Teflon graft will be used to replace an area of weakened heart muscle.

4. Clear the mouth. 71. The best method fort determining if rescue breathing should be performed is to 1. Observe the victims skin color. 2. Feel for pulsations at the neck. 3. Listen for spontaneous breathing. 4. Blow air into the victims mouth. 72. During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at a rate of no less than 1. 15 compressions per minute. 2. 40 compressions per minute. 3. 80 compressions per minute. 4. 100 compressions per minute. 73. When two rescuers perform CPR, the rate of compressions to ventilations is. 1. 15 compressions to 2 breaths. 2. 5 compressions to 1 breath. 3. 1 compression for each breath. 4. 1 compression to 5 breaths.

2. At the fourth intercostals space to the sternum. 3. At the second intercostals space to the right of sternum. 4. At the second intercostals space to the left of sternum. 82. In the postoperative period, the nurse frequently assesses the clients fluid status. What is the rationale for the nurses action? 1. 2. 3. 4. Urinary output retention is common after a heart transplant. Urine output is an indication of perfusion to the kidneys. Hydration determines when the client needs to be transfused. Hydration indicates when fluids should be increased.

A physician writes an order for the application of wet-to-dry dressing over the venous stasis ulcers.

74.

Which evidence best determines when the cardiac compressions can be discontinued? 1. The victims color improves. 2. The pupils become dilated. 3. A pulse can be palpated. 4. The victim begins to vomit.

1. 2. 3. 4.

75. The nurse monitors the clients lab values because of the large doses of diuretics the client received to treat her pulmonary edema. Which lab value must the nurse report immediately to the physician? Sodium 137 mEq/L Potassium 2.5 mEq/L Chloride 97 mEq/L Bicarbonate 25 mEq/L 76. If the clients develops digitalis toxicity, she is most likely to exhibit. 1. Anorexia and nausea 2. Dizziness and insomnia. 3. Pinpoint pupils and double vision. 4. Ringing in the ears and itchy skin. 77. Before administering the digoxin (Lanoxin) to the client, it essential that the 1. Heart rate. 2. Blood pressure. 3. Heart sounds. 4. Lung sounds. the nurse assess

83. When the client asks the nurse why the dressings are being applied, the best explanation is that these dressing help to 1. Prevent wound infections. 2. Remove dead cells and tissue. 3. Absorb blood and drainage. 4. Protect the skin from injury. 84. The client develops a thrombus in one of her leg veins. When the nurse assesses for Homans sign. 1. the client will experience sharp calf pain immediately. 2. The client will complain of sudden numbness in her foot. 3. The client will be unable to bend her knee when asked. 4. The client will feel tingling throughout her affected leg. The physician orders heparin calcium (Calciparine) 7500 U subcutaneously. 85. When the client asks why she is receiving the medication, the most appropriate nursing response is that heparin 1. Helps shrink blood clots. 2. Helps dissolve blood clots. 3. Prevent more clots from forming 4. Prevents the clot from dislodging. 86. When the nurse withdraws the heparin calcium from the multidose vial, which technique is most accurate? 1. The nurse removes the rubber stopper in the top of vial. The nurse instills an equal volume of air as liquid to be withdrawn 3. The nurse mixes the drug by rolling it in the palms of the hands 4. the nurse shakes the drug vigorously to distribute the drug evenly 87. When the nurse administers the heparin subcutaneously to the client of average weight for her height, which action is most accurate? 1. The nurse selects the dorsogluteal site 2. The nurse uses a 220gauge, 1 inch needle The nurse inserts the needle at 45o angle 4. the nurse massages the site immediately after ward A nurse applies prolonged pressure to an injection site of client who is receiving anticoagulant therapy 88. The nurse actions is 1. inappropriate because it promotes hematoma formation 2. inappropriate because it delays drug absorption 3. appropriate because it distributes the drug evenly 4. appropriate because it diminishes blood loss 89. The first action the nurse should take if phlebitis is suspected at an intravenous site is to 1. elevate the affected extremity on pillows 2. apply pressure to the intravenous insertion site 3. administer the intravenous solution at a fast rate 4. remove the needle or catheter from the current site The nurse prepares to use a Doppler ultrasound device to assess blood flow through the dorsalis pedis artery

78. Before cardioversion is attempted, the nurse is most correct in withholding which prescribed medication? 1. Diazepam (Valium) 2. Digoxin (Lanoxin) 3. Heaprin (Lipo-sodium) 4. Glyburide (DiaBeta) 79. The best evidence that the cardioversion procedure has been successful is 1. The client regains consciousness immediately. 2. Normal sinus cardiac rhythm is restored. 3. The apical heart rate equals the radial rate. 4. The pulse pressure is approximately 40 mm Hg. 80. As part of the discharge instructions, the nurse most correctly instructs the client with an artificial pacemakers that a sign pacemaker malfunction. 1. Tingling in the chest pain. 2. Dizziness during activity. 3. Pain radiating to the arm. 4. Tenderness beneath the skin. 81. The best location for the nurse to auscultate the sounds from the mitral valve is 1. At the fifth intercostals space in the midclavicular line.

2.

3.

90. Which technique is most accurate when using the Doppler device? 1. the nurse places the probe beside the ankle 2. the nurse applies acoustic gel to the skin 3. the nurse records the time of capillary refill 4. the nurse measures the temperature of the skin An 18 year old college student has been feeling extremely tired and makes an appointment at the universitys health office 91. Which laboratory test can the nurse expect to be lower than normal if the cause of the clients fatigue is related to irondeficiency anemia? 1. Prothrombin time 2. Bleeding time 3. Fibrinogen level 4. Hemoglobin level 92. For the best absorption of oral iron preparation, the nurse most accurately instruct the client to take ferrous sulfate 1. between meals 2. with each meal 3. just before eating 4. just before bedtime 93. To maximize the absorption of the iron supplement the nurse most accurate advises the client to take the table with 1. milk 2. tea a soft drink 4. orange juice 94. The nurse instructs the client about administering of the liquid iron preparation. Which instruction is most accurate? 1. use a straw 2. pour it in a paper cup 3. take it cover ice 4. mix it with milk 95. Which muscle is best for the nurse to plan to use when giving the injection by Z-track technique? 1. deltoid 2. trapezius 3. gluteus medius 4. latissimus dorsi Laboratory test result indicate that the client with leukemia has a low platelet count. 97. Based on the clients laboratory results, which nursing intervention is most appropriate at this time? 1. limit the clients visitors to family 2. place the client in protective isolation 3. use small-gauge needle for injection 4. provide rest periods between activities The physician informs the client with polycythemia that a phlebotomy will be performed 98. The best evidence that the client understand the physician explanation is when he tells the nurse that 1. blood will be removed from his vein 2. tourniquets will be applied to his arms 3. some veins will be surgically occluded 4. he will receive a blood transfusion The physician orders several laboratory tests for the client suspected of having AIDS 99. Which laboratory test is most significant for diagnosing antibodies to the human immunodeficiency virus (HIV)?

3.

1. 2.
3. 4.

Schick test Dick test enzyme-linked immunosorbent assay (ELISA) venereal disease research laboratory (VDRL) test

100. The nurse explains to the client the anatomic location for the bone marrow aspiration. Which area should the client point to when to identify the site where the specimen will be taken? 1. the posterior hip 2. the lower spine 3. the upper arm 4. the groin area